Understanding the Rural–Urban Differences in Nonmedical Prescription Opioid Use and Abuse in the United States

Katherine M. Keyes, PhD; Magdalena Cerdá, DrPH; Joanne E. Brady, SM; Jennifer R. Havens, PhD; Sandro Galea, MD, DrPH


Am J Public Health. 2014;104(2):e52-e59. 

In This Article

Risk Factors That Drive Illicit Drug Use

Our model of drug use risk factors is grounded in ecosocial theory and ecological systems theory[21,23,24] and is organized by 3 levels of influence that dynamically interact (Figure 1).

Figure 1.

A conceptual framework for the etiology of illicit drug use.

The first is the macro level, where the social context structures the availability of drugs and the norms around use.[25,26] Furthermore, stressors at a macro level such as economic deprivation,[27] inequality,[28] structural discrimination,[29] and other pervasive stressors in the environment may serve as risk factors for drug use.[30,31]

The second is the local context, which includes family dynamics (e.g., supervision, conflict),[32–35] family composition (e.g., older siblings),[36] and family stress (e.g., unemployment). Furthermore, peer influence is a strong correlate of drug use.[37,38]

The third is the micro level. Endogenous factors such as genetic vulnerability,[39] neurobiological factors,[40–42] pharmacological reactivity,[43] personality traits such as sensation seeking and impulsivity,[44,45] psychiatric morbidity,[46–48] and gender and age[49,50] have strong and substantial influences on the propensity to misuse drugs and develop chronic drug dependencies. The pharmacological properties of a drug are important in determining who uses them and how they use them.[22]

These 3 levels of influence interact in dynamic ways; for example, social norms regarding substance use, a contextual influence, may affect how peers interact and form relationships around substance use.[51]